Proximal Humerus 2

Proximal Humerus 2
should I use?

No simple answer exists to this question.

Reduction: Closed to partially open to very open

Fixation: Percutaneous pins, intramedullary nails and rods, sutures, tension bands, T plates, tibial plateau plates, cloverleaf plates, screws, K-wires, staples, trans-osseous wires

Five considerations when entertaining ANY fixation:

1. Bone quality – will it be possible to obtain and maintain anatomic reduction with rigid fixation? Severe osteoporosis is associated with an exceedingly high rate of complications with internal fixation, regardless of the nature of the reduction (open or closed), even in two part fractures.

2. Vascularity – the more soft tissue dissection required, the higher the chances of AVN

3. Malunion of the tuberosities and the head must be avoided.

4. Nonunion is more likely the more distal the fracture – beware tenuous fixation.

5. Early active rehab is unnecessary and deleterious if minimal internal fixation is used.

Þ Warner, J.J.P., Gerber, C., Alternatives to Hemiarthroplasty for Complex Proximal Humeral Fractures, in Complex and Revision Problems in Shoulder Surgery, ed. Warner, Iannotti, Gerber, Lippincott-Raven, 1997.

– With these considerations in mind for each individual fracture, attempt to determine which method of reduction and fixation is most compatible with the particular fracture.
How good are the results?

Nearly impossible to figure out from the literature. Different rating schemes, different ages, different bone quality, and of course, an inadequate classification to describe them.

Probably the best results come from the avoidance of complications:

Þ Connor P.M., Flatow E.L., Complications of Internal Fixation of Proximal Humeral Fractures, in Instructional Course Lectures, Vol 46, 1997.

Nonunion – aggressive soft-tissue dissection, inadequate reduction, poor internal fixation, comminution, soft tissue interposition, osteopenia, systemic disease, excessive mobilization

Malunion – failure to restore proximal humeral anatomy with internal fixation is consistently associated with unsatisfactory results.
– most commonly result from technical errors in reduction or fixation
– surgical neck: apex anterior angulation > 30o
– GT: 5-10 mm – impingement, pain, stiffness
– LT: (rare) subcoracoid impingement and weak IR

Hardware Loosening: 12.6% incidence of loss of fixation in a review of 349 fractures

Neurovascular injury

Frozen shoulder

Infection

HO

Osteonecrosis

In general, achieving anatomic reduction and rigid fixation,
particularly of the tuberosities, appears to predict a good outcome –
as long as osteonecrosis does not occur…

What is the likelihood of AVN? (whether I fix it or not??)

Incidence reported from 0% to 90%

? What is our ability to diagnose it ? Are the studies following patients long enough to see it???

Þ Neer C.S., Displaced Proximal Humeral Fractures: II. Treatment of Three-Part and Four-Part Displacements. Journal of Bone and Joint Surgery, 52A: 1090-1103. 1970

· 117 patients – 61 three-part, 56 four-part
· Followed for 1 to 16 years, average 4.8. 37 followed from 1-2 years, 46 from 2-5 years, 14 from 5-10 years, and 20 from 10-16 years.
· 31 treated with closed reduction
· 43 treated with open reduction
· 43 treated with hemiarthroplasty.

AVN in only 13 patients (4 of 61 three-part, 9 of 56 four-part)

Whether I fix it or not…..

Þ Hagg O., Lundberg, B., Aspects of Prognostic Factors in Comminuted and Dislocated Proximal Humeral Fractures, in Surgery of the Shoulder, Bateman J.E., Welsh R.P (eds), 1984, pg 51-59

Summarized 10 “comparable” series:

3-part fractures:
· 92 treated closed AVN rate 3-14%
· 84 treated open AVN rate 12-25%

4-part fractures:
· 70 treated closed AVN rate 13-34%
· 49 treated open AVN rate 41-59%

– interestingly, dislocation did not seem to change the incidence of AVN

So yes, AVN does happen whether you fix it or not, but the incidence
does seem to